1 9 09 lecture handout
TRANSCRIPT
Communications and Procedures Communications and Procedures Necessary to Achieve Success Necessary to Achieve Success with Milled Titanium Bars for with Milled Titanium Bars for Attached Overdentures and Attached Overdentures and
Screw Retained Hybrids Screw Retained Hybrids Aristides A. Tsikoudakis, DMDAristides A. Tsikoudakis, DMD
Maxillofacial ProsthodontistMaxillofacial ProsthodontistLakewood, ColoradoLakewood, Colorado
Thomas Wade, C.D.TThomas Wade, C.D.TOwner, New Horizons Dental LaboratoryOwner, New Horizons Dental Laboratory
Broomfield, ColoradoBroomfield, Colorado
ObjectivesObjectivesReview of fundamentalsReview of fundamentals
Initial exam and work upInitial exam and work upDiagnosisDiagnosisPatient expectationsPatient expectations
Classification of ProsthesesClassification of ProsthesesImplant supportedImplant supportedImplant assistedImplant assisted
Case presentationCase presentationDetailed examination of restorative and lab componentsDetailed examination of restorative and lab components
Initial ExamInitial Exam
Critical ElementsCritical ElementsExtra-oral:Extra-oral:
TMJTMJNeckNeckSoft TissuesSoft Tissues
Initial ExamInitial Exam
Intra-oral:Intra-oral:Soft TissuesSoft TissuesChartingChartingEdentulous evaluationEdentulous evaluation
Initial ExamInitial ExamRadiographic ExaminationRadiographic Examination
Orthopantogram Vs. TomogramOrthopantogram Vs. Tomogram
Initial ExamInitial Exam
Diagnostic CastsDiagnostic CastsImpressionsImpressionsJaw relation recordsJaw relation recordsFacebowFacebowMountingMountingTooth selectionTooth selection
Initial ExamInitial ExamDiagnostic CastsDiagnostic Casts
If patients existing dentures have If patients existing dentures have adequate form and function then…adequate form and function then…
Denture Information TransferDenture Information Transfer
Initial ExamInitial ExamDiagnostic Set-UpDiagnostic Set-Up
Chairside arrangement of anterior teethChairside arrangement of anterior teeth
MidlineMidlineLabial contour (lip support)Labial contour (lip support)Smile lineSmile lineTooth displayTooth displayPhoneticsPhonetics
Initial ExamInitial ExamLab Hints:
Set-up wax
Positioning technique
Adjusting existing set-upPhotos are always welcome
Casts of existing prostheses
Initial ExamInitial ExamDiagnosis:
Edentulous
Degree of resorptionIntact alveolar volume, missing clinical crownDeficient alveolar/soft tissue volume
Skeletal-occlusal relationship
Pathology
Initial examInitial examEstablishing Patient ExpectationsEstablishing Patient Expectations
Listen
Interpret
Confirm
ClassificationClassification
Implant SupportedImplant SupportedForces are borne entirely by the implants Forces are borne entirely by the implants without support from the soft tissuewithout support from the soft tissue
Implant AssistedImplant AssistedSupport is shared between implants and Support is shared between implants and soft tissuesoft tissue
Clinical StepsClinical StepsNumber of Visits: 6-8Number of Visits: 6-8
Preliminary impressionsPreliminary impressionsVerification and master impressionsVerification and master impressions
Ant set-up and jaw recordsAnt set-up and jaw recordsWax try-inWax try-inSubstructure try-inSubstructure try-inClinical remount & deliveryClinical remount & delivery
1:001:002:002:001:001:001:001:001:001:001:301:30
ObjectivesObjectivesPhoto Montage…Photo Montage…
Guided surgery Guided surgery All-0n-4All-0n-4Radiographic guidesRadiographic guidesMilled titanium barsMilled titanium bars
Troubleshooting common problemsTroubleshooting common problemsAccurate impressions and proper castsAccurate impressions and proper castsInformation & communicationInformation & communication
Treatment planningTreatment planningCollaboration between surgeon, restorative, labCollaboration between surgeon, restorative, lab
Troubleshooting Troubleshooting ““If you don’t have time to do it correctly If you don’t have time to do it correctly the first time…the first time…
When are you going to have time to do it When are you going to have time to do it over?”over?”
Troubleshooting Troubleshooting Accurate impressions: sets level of excellenceAccurate impressions: sets level of excellence
Custom tray when indicated Custom tray when indicated
Adhesive (PVS & Alginate)Adhesive (PVS & Alginate)
Proper proportions (alginate & polysulfide)Proper proportions (alginate & polysulfide)
Read itRead it
Retake if necessaryRetake if necessary
Troubleshooting Troubleshooting CastsCasts
Properly poured and based castsProperly poured and based castsHeelsHeelsAvoid mandibular horseshoe castsAvoid mandibular horseshoe castsInspect prior to sending to lab (pack properly)Inspect prior to sending to lab (pack properly)
Selection of appropriate gypsumSelection of appropriate gypsumPlaster: Plaster: neverneverDie stone: splints, implants, RPD Die stone: splints, implants, RPD Stone: everything elseStone: everything else
Troubleshooting Troubleshooting Information and CommunicationInformation and Communication
Case info: more is Case info: more is ALWAYSALWAYS better than not better than not enoughenoughgendergenderageageshade, opposing cast, jaw record shade, opposing cast, jaw record photos photos (important for tooth selection)(important for tooth selection)accurate extraction infoaccurate extraction infocast of existing prosthesescast of existing prostheses
Troubleshooting Troubleshooting Relines and adding teeth/clasp to RPD:Relines and adding teeth/clasp to RPD:
Pick-up impressionPick-up impression
Alginate vs. PVSAlginate vs. PVS
Proper pouring techniqueProper pouring technique
Treatment PlanningTreatment PlanningCollaborative EffortCollaborative Effort
SurgeonSurgeon
Restorative Dr.Restorative Dr.
Lab technicianLab technician
Treatment PlanningTreatment PlanningGoal:Goal:
To devise the most predictable and straight To devise the most predictable and straight forward approach for meeting the patient’s forward approach for meeting the patient’s expectationsexpectations
Essentially comes down to 2 factors:Essentially comes down to 2 factors:Patient expectationsPatient expectationsBone: where and how muchBone: where and how much
Treatment PlanningTreatment PlanningCases: Implant Supported Fixed vs. RemovableCases: Implant Supported Fixed vs. Removable
Component stacking phenomenonComponent stacking phenomenon
Minimum dimensionsMinimum dimensionsMetal-ceramic 4.5 to 5mmMetal-ceramic 4.5 to 5mmFixed hybrid 9mmFixed hybrid 9mmRemovableRemovable 16mm 16mm
Treatment PlanningTreatment Planning
Decisions: Implant supported vs. Assisted Decisions: Implant supported vs. Assisted Selected by patientSelected by patient
Fixed vs. RemovableFixed vs. RemovableDepends on: DefectDepends on: Defect
Interocclusal Interocclusal spacespace
* Surgery: modify existing anatomy* Surgery: modify existing anatomy
Treatment PlanningTreatment PlanningOnce a treatment plan has been Once a treatment plan has been
devised…devised…
What criteria are used to select What criteria are used to select appropriate implant system?appropriate implant system?
What about radiographic/surgical guide?What about radiographic/surgical guide?
Treatment PlanningTreatment PlanningImplant system selection criteria:Implant system selection criteria:
Splinted vs. non-splintedSplinted vs. non-splinted
Angled implant placementAngled implant placement
Guided implant placementGuided implant placement
Treatment PlanningTreatment PlanningRadiographic / Surgical Guides Radiographic / Surgical Guides
Treatment PlanningTreatment PlanningRadiographic / Surgical Guides Radiographic / Surgical Guides
10o
Treatment PlanningTreatment PlanningGuidelines:Guidelines:
Determine visibility of the residual ridgeDetermine visibility of the residual ridge
Presence or absence of composite defectPresence or absence of composite defect
Biomechanics (force control)Biomechanics (force control)
Bedrossian et al. Implant restoration of the edentulous maxilla: a systematic pretreatment evaluation method. J. Oral Maxillofac Surg 66:112-122, 2008
Treatment PlanningTreatment PlanningImplant Supported vs. Implant Assisted
Transition
Composite Defect
Interocclusal Space
yes
yes
no no
PFMODSurgery
PFMODSRH
SRHOD
PFM
5-8 mm
9+ mm 16+ mm
PFM SRH OD
*Surgical modification
Treatment PlanningTreatment PlanningGuidelines:Guidelines:
Biomechanics (force control)Biomechanics (force control)
Reduce forces applied to systemReduce forces applied to system
Engineer system to withstand forcesEngineer system to withstand forces
Treatment PlanningTreatment PlanningGuidelines:Guidelines:
Biomechanics (force control)Biomechanics (force control)
Bone in premaxilla, premolar and molar area:Bone in premaxilla, premolar and molar area:
conventional implant placementconventional implant placementgreatest A-P spread possiblegreatest A-P spread possible
Treatment PlanningTreatment PlanningGuidelines:Guidelines:
Biomechanics (force control)Biomechanics (force control)
Bone in premaxilla and bicuspid Bone in premaxilla and bicuspid only:only:
Angled implantsAngled implantsSinus graftSinus graft
Treatment PlanningTreatment PlanningGuidelines:Guidelines:
Biomechanics (force control)Biomechanics (force control)
Bone in premaxilla only:Bone in premaxilla only:
Sinus graftSinus graftZygomatic implantZygomatic implantImplants in cuspid sitesImplants in cuspid sites
Treatment PlanningTreatment PlanningGuidelines:Guidelines:
Biomechanics (force control)Biomechanics (force control)
Bone deficient in all zones:Bone deficient in all zones:
Zygomatic implants x 4Zygomatic implants x 4
Treatment PlanningTreatment PlanningGuidelines:Guidelines:
Biomechanics (force control)Biomechanics (force control)
Minimize cantilever of substructureMinimize cantilever of substructureStress relieving design for implant Stress relieving design for implant
assistedassistedProper material thicknessProper material thicknessReinforcement as needed Reinforcement as needed
Treatment PlanningTreatment PlanningGuidelines:Guidelines:
Biomechanics (force control)Biomechanics (force control)Stress relieving ?
Reinforcement
Treatment PlanningTreatment PlanningAttachment: Criteria for selectionAttachment: Criteria for selection
Implant Supported:Implant Supported:Only needed for retentionOnly needed for retentionMinimal heightMinimal heightEasy & inexpensive to replace insertEasy & inexpensive to replace insertReadily availableReadily availableMinimize wear between componentsMinimize wear between components
Treatment PlanningTreatment PlanningAttachment: Criteria for selectionAttachment: Criteria for selection
Implant Assisted:Implant Assisted:RetentionRetentionMinimal heightMinimal heightEasy & inexpensive to replace insertEasy & inexpensive to replace insertReadily availableReadily availableMinimize wear between componentsMinimize wear between componentsResilientResilientAllows for rotation Allows for rotation
Treatment PlanningTreatment PlanningEstablishing FeesEstablishing Fees
3-4 x lab cost to Dr.3-4 x lab cost to Dr.
Dental Fee AnalyzerDental Fee Analyzer
ChairtimeChairtime
Treatment PlanningTreatment PlanningEstablishing FeesEstablishing Fees
RangesRanges
MaxillaryMaxillary Mandibular Mandibular
PFM (8) PFM (8) $19,100-$27,300 $19,100-$27,300PFM (6) $17,700-$25,300PFM (6) $17,700-$25,300SRH (8) SRH (8) $15,000-$21,400 $15,000-$21,400SRH (6) $14,200-$20,400SRH (6) $14,200-$20,400SRH (4) SRH (4) $13,600-$19,500 $13,600-$19,500SRH (4) $13,600-$19,500SRH (4) $13,600-$19,500OD w/Bar (4) $7,000-$10,000 OD w/Bar (4) $7,000-$10,000OD w/Bar (4) $7,000-$10,000 OD w/Bar (4) $7,000-$10,000 OD w/Bar (2) $5,600-$8,000OD w/Bar (2) $5,600-$8,000
Treatment PlanningTreatment PlanningQuestions?
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